The results of closing wedge osteotomy with posterior instrumented fusion for the surgical treatment of congenital kyphosis

Purpose

There exist not much data regarding the surgical treatment of pure congenital kyphosis (CK) in the literature. The purpose of this study was to evaluate the results of closing wedge osteotomy with posterior instrumented fusion in patients with congenital kyphotic deformity.

Methods

We retrospectively evaluated the radiographical results of 10 patients who were subject to closing wedge vertebral osteotomy and posterior instrumented fusion due to CK. The mean age of the patients at surgery was 12.6 ± 3.72 years (range 8–18 years). Radiographical measurements including local kyphosis, correction loss, global kyphosis and sagittal balance values were noted for the preoperative, postoperative and final follow up periods, respectively. The data obtained from those periods underwent statistical analysis.

Results

Average follow-up period was 51.8 ± 29.32 months (range 26–96 months). The mean local kyphosis angle was 67.7° ± 15.64° (range 42°–88°) prior to the surgery, 31.5° ± 17.12 (range 14°–73°) following the surgery and 31.9° ± 15.98° (range 14°–71°) during the follow up-period, respectively (p < 0.05). A correction rate of 53.5 % was reported at the final follow up. Average sagittal balance was measured as 33.1 ± 24.48 mm (range 2–77 mm) prior to the surgery, 20.8 ± 15.46 mm (range 5–46 mm) following the surgery (p < 0.05) and 14.1 ± 9.2 mm (range 0–30 mm) during follow-up period (p > 0.05). Complications consisted of a rod fracture due to pseudoarthrosis, an implant failure with loosening of screws and a proximal junctional kyphosis. No neurological deficit or deep infection were encountered in any of the patients in the study group.

Conclusion

Closing wedge osteotomy with posterior instrumented fusion is an efficient method of surgical treatment in terms of sagittal balance restoration and deformity correction in patients with congenital kyphosis.     

Pedikelsubtraktionsosteotomie mit dorsaler Wedge-Osteotomie

Background

The purpose of the study was to evaluate the clinical and radiological follow-up of patients suffering from fixed post-traumatic and postinflammatory kyphotic deformities of the thoracic and lumbar spine and treated by posterior transpedicular wedge resection osteotomy of the spine.

Methods

A total of 28 patients received a posterior transpedicular wedge resection osteotomy. A prospective follow-up was performed preoperatively, postoperatively and after 3, 6 and 12 months. The kyphotic angle of the fractured segment was evaluated as well as the clinical parameters the self-reported visual analog scale (VAS) and the Oswestry score.

Results

The median pain scores (VAS) and the Oswestry disability scores (p<0.05) decreased significantly from pretreatment to post-treatment. Postoperatively a significant correction of the kyphotic angle could be achieved with a mean of 28° (range 14-44°). In the follow-up after 1 year there was a 7° increase in kyphosis.

Conclusions

Transpedicular wedge resection osteotomy of the thoracic and lumbar spine offers a safe surgical technique for the treatment of fixed postinflammatory kyphotic deformities.     

The posterior surgical correction of congenital kyphosis and kyphoscoliosis: 23 cases with minimum 2 years follow-up

Purpose

The purpose of this study is to review our operative experience of congenital kyphosis or kyphoscoliosis undergoing either pedicle subtraction osteotomy (PSO) or posterior vertebral column resection (pVCR) according to certain criteria we have established.

Methods

From December 2003 to 2009, 23 consecutive patients of congenital kyphosis or kyphoscoliosis were treated by means of PSO or pVCR procedure in a single institution. The average preoperative kyphosis angle was 74.3º. The C7 plumb line was 12.6 mm posterior to the posterior–superior corner of S1 on average, showing negative imbalance. In the 11 cases who had accompanied scoliosis, the average preoperative scoliosis angle was 42.6º. The average Oswestry Deficiency Index (ODI) for back pain was 14.6 before surgery. Eleven patients had compromise of neurological functions.

Results

After PSO or pVCR procedure, the average kyphosis angle decreased to 20.0º, and the accompanied scoliosis also decreased to 15.8º. The average follow-up time after surgery was 34.3 months. At the last follow-up, the average kyphosis corrective rate was 73.7 %, and the average scoliosis corrective rate was 61.7 %. The negative imbalance improved, with the C7 plumb line being 1.5 mm posterior to the posterior–superior corner of S1 on average. After surgery, the average ODI for back pain had 40.6 % improvement, and most patients who had neurological symptoms before surgery had varying degrees of relief. The total satisfactory rate to corrective surgery was 91.3 %. No permanent neurological damage was observed.

Conclusions

If selected appropriately, both PSO and pVCR procedures can achieve compatible and satisfactory correction results in the surgical treatment of congenital kyphosis or kyphoscoliosis.     

Surgical treatment of thoracic spinal tuberculosis with adjacent segments lesion via one-stage transpedicular debridement, posterior instrumentation and combined interbody and posterior fusion, a clinical study

Purpose

To investigate the clinical efficacy and feasibility of one-stage surgical treatment for thoracic spinal tuberculosis with adjacent segments lesion by internal fixation, transpedicular debridement, and combined interbody and posterior fusion via a posterior-only approach.

Materials and methods

Twenty-one patients (thirteen males, eight females) with thoracic tuberculosis whose lesions were confined to two adjacent segments were studied retrospectively. All patients were treated with one-stage surgical treatment by internal fixation, transpedicular debridement, and combined interbody and posterior fusion via a posterior-only approach. The American Spinal Injury Association (ASIA) impairment scale was used to assess neurological function. Thoracic Cobb angle was used to assess thoracic kyphosis. Operating time, blood loss, complications, neurological function, deformity correction and interbody fusion were investigated.

Results

Average mean operating time was 231.4 ± 31.9 min, and evaluated blood loss during operation was 880.2 ± 112.7 ml. All patients were followed up for 22–41 months postoperatively (average 29.8 ± 5.4 months). All patients had significant postoperative improvement in ASIA classification scores. The thoracic kyphotic angles were significantly decreased to 9°–25° postoperatively (average 16.7° ± 4.4°), and at final follow-up were 10°–27°(average 17.7° ± 4.4°). No severe complications or spinal cord injury occurred. The erythrocyte sedimentation rate recovered to normal within 3 months postoperatively in all patients. All patients got bony fusion within 6–9 months after surgery.

Conclusions

One-stage transpedicular debridement, posterior instrumentation and combined interbody and posterior fusion via a posterior-only approach can be an effective and feasible treatment method for thoracic spinal tuberculosis.     

Skip pedicle screw fixation combined with Ponte osteotomy for adolescent idiopathic scoliosis

Purpose

This study aimed to determine whether Ponte osteotomy combined with skip pedicle screw fixation (SPSF) can improve the correction rate and restore thoracic kyphosis for patients with adolescent idiopathic scoliosis.

Methods

Surgical time, blood loss, preoperative Cobb angle of the main thoracic curve, flexibility, Cobb angle at 1 year after surgery, thoracic curve correction rate, and Cincinnati correction index (CCI) were determined for both the Ponte (n = 17) and non-Ponte (control; n = 21) groups. Furthermore, kyphotic angles at T5–T12 before and 1 year after the surgery were measured.

Results

The following measurements were obtained for the Ponte and control groups, respectively: surgical time, 236 ± 13 and 187 ± 9 min; blood loss, 1,141 ± 150 and 745 ± 120 g; preoperative Cobb angle of the main thoracic curve, 52.5° ± 10.4° and 51.5° ± 9.2°; flexibility, 31.7 ± 13.2 and 45.1 ± 12.3 % (p = 0.003); thoracic curve correction rate, 62.0 ± 2.5 and 63.6 ± 2.5 %; CCI, 2.2 ± 0.2 and 1.5 ± 0.1 (p = 0.003); preoperative kyphotic angle at T5–T12, 11.3° ± 11.2° and 13.0° ± 9.0°; and kyphotic angle at T5–T12 at 1 year after the surgery, 21.8° ± 1.7° and 24.2° ± 1.9°.

Conclusion

Ponte osteotomy was combined with SPSF in case of rigid curve. CCI was significantly greater in the Ponte group. Postoperative thoracic kyphotic angles were identical in both groups.     

Multiple concave rib head resection improved correction rate of posterior spine fusion in treatment of adolescent idiopathic scoliosis

Background

Hybrid constructs have been widely used to surgically correct thoracic adolescent idiopathic scoliosis (AIS). To enhance the correction obtained with hybrid constructs, we perform concave rib head resection and convex costovertebral release as posterior release procedures. The objective of the study was to evaluate coronal and sagittal curve correction in patients with adolescent idiopathic scoliosis (AIS) treated with hybrid constructs combined with concave rib head resection and convex transverse process resection as posterior release procedures.

Two-level pedicle subtraction osteotomy for severe thoracolumbar kyphotic deformity in ankylosing spondylitis

Study design

A retrospective clinical study.

Objective

To evaluate the outcomes of two-level (T12 and L3) pedicle subtraction osteotomy (PSO) for severe thoracolumbar kyphosis in ankylosing spondylitis (AS), and to discuss the surgical strategies of this surgery.

Background

Cases were limited on the results of two-level PSO for correction of severe kyphosis caused by AS, nor on surgical strategies of this type of surgery.

Methods

From March 2006 to December 2010, nine consecutive AS patients with severe kyphotic deformity, underwent T12 and L3 PSOs. Chin-brow vertical angle (CBVA) and radiographic assessments which contain thoracic kyphosis (TK), lumbar lordosis (LL), global kyphosis (GK), and sagittal vertical axis were carefully recorded pre and postoperatively to evaluate the sagittal balance. Intra and postoperative complications were also registered. All patients were asked to fill out Oswestry Disability Index before surgery and at the last follow-up visit.

Results

All nine patients (8M/1F), averaged 41.4 years old (range 35–51 years), were received two-level (T12 and L3) PSO, and were followed up after surgery for a mean of 39.9 months (range 24–68 months). Good cosmetic results were achieved in all patients. Mean correction at two-level PSO was 67.9 ± 5.5°. All CBVA, TK, LL, and GK were changed significantly after surgery (P < 0.05), the mean amount of correction of which were 59.5 ± 13.8, 34.7 ± 3.8, 33.2 ± 2.4, and 54.0 ± 14.8 degrees, respectively, and with a small loss of correction at the last follow-up visit. Sagittal imbalance was significantly improved from 27.3 ± 4.4 to 3.4 ± 0.7 cm postoperatively. Neither mortalities nor any major neurological complications were found. The mean ODI score was significantly improved from 53.4 ± 15.5 before surgery to 8.2 ± 4.7 at the last visit.

Conclusion

The outcomes of follow-up showed that two-level (T12 and L3) PSO can effectively and safely correct severe thoracolumbar kyphosis in AS.     

Effectiveness of pedicle screw-based ligamentotaxis in reducing preoperative kyphosis in thoracolumbar spinal fractures: a retrospective analytical study based on injury surgery interval

Objectives

Although there is an agreement of using long-level construct than short-level construct to correct the kyphosis, no literature mentioned the success of this treatment based on timing of surgery after the injury. Objective of this paper was to study the effect of ligamentotaxis on preventing the development of postoperative kyphosis in unstable thoracolumbar burst fractures based on injury surgery interval (ISI).

Study design

This is a retrospective analysis in 67 patients with unstable thoracolumbar burst fractures operated with posterior-only pedicle screw fixation.

Methods

A retrospective analytical study was conducted in 67 patients who had unstable thoracolumbar fracture and operated with posterior-only pedicle screw construct two levels above and one level below the fractured vertebra. Results were analyzed based on ISI: group 1 (34 patients) was operated within 7 days; group 2 (19 patients) operated between 7 and 14 days; and group 3(14 patients) operated after 14 days of injury. Immediate postoperative and final follow-up kyphotic angles were analyzed among all three groups using Kruskal–Wallis test. Complications regarding implant failure were also noted at final follow-up.

Results

Average follow-up was 37 ± 8.1 months. Average preoperative kyphosis at thoracolumbar junction was 26.3° ± 3.9°, 26.3° ± 2.9° and 26.3° ± 2.8° in groups 1, 2 and 3, respectively, which did not show any difference (P = 0.98). Immediate postoperatively kyphotic angle was improved to 4.3° ± 1.9°, 5.4° ± 1.7° and 10.1° ± 3.0° in groups 1, 2 and 3, respectively, which exhibited statistically significant difference (P < 0.001); and at final follow-up kyphotic angles were 5.4° ± 1.9°, 7.2° ± 1.7° and 15.0° ± 1.6° in groups 1, 2 and 3, respectively showing 1.1°, 1.7° and 4.9° loss in correction at final follow-up. Comparison of kyphotic angles and loss of kyphotic angles amongst the three groups showed statistically significant difference (P < 0.001). Two patients from group 3 had implant failure that required implant extraction.

Conclusion

Posterior-only pedicle screw fixation in unstable thoracolumbar fractures would correct and maintain the postoperative correction in kyphosis, at least at 3-year follow-up, without increasing implant failure if ISI is less than 2 weeks. While patients operated after 2 weeks of injury would require additional anterior procedure.     

Predictors of kyphotic deformity in osteoporotic vertebral compression fractures: a radiological study

Purpose

To report the radiological predictors of kyphotic deformity in osteoporotic vertebral compression fractures (OVCF).

Methods

This is a retrospective study of 64 consecutive patients with OVCF. We studied the radiographic features in the immediate post-injury image of patients, who developed significant (more than 30°) segmental kyphotic deformity at final follow-up and compared them with those patients who did not.

Results

Thirty-three (82.5 %) out of 40 patients with fracture at thoracolumbar (TL) junction, 5 (33.3 %) patients out of 15 with fracture at lumbar (L) spine and 7 (77.7 %) patients out of 9 with fracture at thoracic (T) spine developed significant segmental kyphotic deformity. Forty-one (75.9 %) [TL-33 (80.5 %), L-4 (33.33 %) and T-4 (80 %)] out of 54 [TL-37 (68.51 %), L-12 (22.23 %) and T-5 (9.26 %)] patients with superior endplate fracture developed significant segmental kyphotic deformity. Forty patients (86.9 %) [TL-28 (70 %), L-6 (15 %) and T-6 (15 %)] out of 46 [TL-32 (69.56 %), L-8 (17.4 %) and T-6 (13.04 %)] with anterior cortical wall fracture developed significant segmental kyphotic deformity. Five patients (71.42 %) [TL-2 (40 %) and T-3 (60 %)] out of 7 [TL-02 (28.58 %), L-01 (14.28 %), T-04 (57.14 %)] with adjacent level fracture developed significant segmental kyphotic deformity. The average immediate post-injury kyphosis of 11° (5°–25°) increased to 29° (15°–50°) at final follow-up.

Conclusion

Progressive segmental kyphotic collapse following an OVCF seems unavoidable. Patients with TL junction and superior endplate fracture are probably at the highest risk for significant segmental kyphotic deformity.     

Preventive effects of conservative treatment with short-term teriparatide on the progression of vertebral body collapse after osteoporotic vertebral compression fracture

Summary

The progression of fractured vertebral collapse is not rare after a conservative treatment of vertebral compression fracture (VCF). Teriparatide has been shown to directly stimulate bone formation and improve bone density, but there is a lack of evidence regarding its use in fracture management. Conservative treatment with short-term teriparatide is effective for decreasing the progression of fractured vertebral body collapse.

Introduction

Few studies have reported on the prevention of collapsed vertebral body progression after osteoporotic VCF. Teriparatide rapidly enhances bone formation and increases bone strength. This study evaluated preventive effects of short-term teriparatide on the progression of vertebral body collapse after osteoporotic VCF.

Methods

Radiographs of 68 women with single-level osteoporotic VCF at thoracolumbar junction (T11–L2) were reviewed. Among them, 32 patients were treated conservatively with teriparatide (minimum 3 months) (group I), and 36 were treated with antiresorptive (group II). We measured kyphosis and wedge angle of the fractured vertebral body, and ratios of anterior, middle, and posterior heights of the collapsed body to posterior height of a normal upper vertebra were determined. The degree of collapse progression was compared between two groups.

Results

The progression of fractured vertebral body collapse was shown in both groups, but the degree of progression was significantly lower in group I than in group II. At the last follow-up, mean increments of kyphosis and wedge angle were significantly lower in group I (4.0°?±?4.2° and 3.6°?±?3.6°) than in group II (6.8°?±?4.1° and 5.8°?±?3.5°) (p?=?0.032 and p?=?0.037). Decrement percentages of anterior and middle border height were significantly lower in group I (9.6?±?10.3 and 7.4?±?7.5 %) than in group II (18.1?±?9.7 and 13.8?±?12.2 %) (p?=?0.001 and p?=?0.025), but not in posterior height (p?=?0.086).

Conclusions

In female patients with single-level osteoporotic VCF at the thoracolumbar junction, short-term teriparatide treatment did not prevent but did decrease the progression of fractured vertebral body collapse.     

Accuracy of spinal curvature assessed by a computer-assisted device and anthropometric indicators in discriminating vertebral fractures among individuals with back pain

Summary

This study examined the accuracy of thoracic and lumbar kyphotic angles as well as anthropometric indicators for discriminating patients with vertebral fracture among Japanese women >50 years old with back pain. Along with region-specific kyphotic angles and anthropometric indicators, the combination of thoracic and lumbar kyphotic angles offered the highest accuracy.

Introduction

Vertebral fractures have been associated with thoracic kyphosis. However, reports on lumbar kyphotic changes in association with vertebral fracture are scarce. This study investigated the accuracy of thoracic kyphotic angle (TKA) and lumbar kyphotic angle (LKA) measurements as well as anthropometric indicators (wall–occiput distance (WOD) and rib–pelvis distance (RPD)) in discriminating patients with vertebral fracture.

Methods

Lateral radiographs of the spine were obtained in 70 postmenopausal Japanese women who visited an orthopedic clinic with low back pain (mean age, 76.2?±?9.0 years). Radiographic vertebral fracture was diagnosed using quantitative measurement according to Japanese criteria. Osteoarthritis (OA) was defined as Kellgren–Lawrence (KL) grade 3 or higher. TKA and LKA were measured using SpinalMouse®. WOD and RPD were also measured.

Results

At least one vertebral fracture was present in 49 subjects (70 %). Women with vertebral fractures showed significant increases in LKA, TKA?+?LKA, and WOD and decreases in RPD. Logistic regression analysis showed significant association between TKA?+?LKA and vertebral fracture independent of the presence of OA. Receiver operating characteristic analysis revealed that TKA was useful for discriminating thoracic fractures (area under the curve (AUC), 0.730) and LKA was useful for lumbar fractures (AUC, 0.691). The combination of TKA?+?LKA offered the highest accuracy for detecting thoracic, lumbar, and any vertebral fractures, with AUCs of 0.779, 0.728, and 0.783, respectively. WOD and RPD showed low-to-moderate accuracies for thoracic, lumbar, and any vertebral fractures.

Conclusions

Assessment of spinal kyphosis by SpinalMouse® as well as anthropometric indicators proved useful in discriminating subjects with vertebral fractures. These convenient and radiation-free methods could contribute to early diagnosis of vertebral fractures and subsequent appropriate treatment, thus preventing additional osteoporotic fractures.     

Thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage

Purpose

Retrospective analysis of the clinical efficacy and feasibility of patients with thoracolumbar spinal tuberculosis with psoas abscesses treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.

Method

A total of 18 patients with thoracolumbar tuberculosis (TB), between February 2007 and February 2011, underwent one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage. And the clinical efficacy was evaluated based on surgery duration time, the blood loss, the postural drainage of time, neurological status that was recorded by American Spinal Injury Association (ASIA) Impairment Scale, the fate of bone graft fusion, kyphosis angle, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP), which were collected at certain time.

Results

The average follow-up period was 34 months (range 18–48 months). 18 patients suffered from seriously neurological deficits pre-operatively, of which 16 patients returned to normal at final follow-up. The surgery duration time was 197 ± 37.9 min, and the blood loss was 815 ± 348.5 ml. The postural drainage of time was 7.2 ± 2.7 days. The psoas abscesses disappeared in all cases, within the time range of 6–9 months (mean 7.4 ± 1.2 months). All patients of the grafted bones were thoroughly fused, with a fusion time ranging from 4 to 12 months (mean 7.8 months). Kyphosis angle was 44.32 ± 7.26° on average pre-operative and returned to 11.72 ± 2.85° at 6 weeks after operation; kyphosis angle was 13.10 ± 2.39° at final follow-up. The values of ESR and CRP were significant declined at 6 weeks post-operative, and returned to normal levels at final follow-up.

Conclusion

With standardized anti-TB chemotherapy, thoracolumbar spinal tuberculosis with psoas abscesses could be effectively treated by one-stage posterior transforaminal lumbar debridement, interbody fusion, posterior instrumentation, and postural drainage.     

Non-instrumented correction of cervicothoracic kyphosis in ankylosing spondylitis: a critical analysis on the results of open-wedge osteotomy C7-T1 with gradual Halo-Thoracic-Cast based correction

Introduction

With progression of cervicothoracic kyphosis (CTK), ankylosing spondylitis (AS) patients suffer functional disability. Surgical correction still poses neurologic risks, while evidence of an ideal technique preventing its complications is weak.

Materials and methods

We report our results with non-instrumented correction in perspective of a review of literature, serving as an important historical control. Database review identified 18 AS patients with CTK correction. After application of a Halo-Thoracic-Cast (HTC) patients underwent posterior non-instrumented open-wedge osteotomy at C7/T1 and osteotomy closure by threaded HTC-rod adjustments. Postoperative gradual HTC correction was continued for 2–4 weeks. Patients were invited for follow-up and medical charts were reviewed for demographics, surgical details, complications and outcomes. The patients’ preoperative, postoperative, before HTC removal and follow-up photographs were analyzed for the Chin-Brow-Vertical-Angle (CBVA), radiographs for the CTK angle.

Results

Patients’ age was 50 ± 11 years, follow-up was 37 ± 47 months and CBVA correction was 25° ± 9° (p < 0.000001). The final radiographic correction at follow-up was 20° ± 11° (p = 0.00002). At the latest follow-up, three patients judged their outcome as excellent, nine good, three moderate and one poor. Upon invitation, seven patients appeared with follow-up averaging 87 months. Neck-pain disability index was 8 ± 14 %. Two patients died, three were lost, one had revision elsewhere and five just had a routine follow-up. Six patients sustained a minor and ten a major complication. Revisions were indicated in five patients including infection, C8-radiculopathy and neurologic events by translation at the osteotomy. A total of 44 % of patients showed translation at the osteotomy indicating acute surgery with instrumentation twice after osteotomy closure, three patients had a revision posterior decompression and instrumented fusion for sequels related to translation.

Conclusion

With the non-instrumented HTC-based technique, average CBVA correction of 25° was achieved and all patients were ambulatory at follow-up. However, regarding translation at the osteotomy, loss of correction, morbidity of the HTC and lack of control at the osteotomy instrumentation-based correction and instrumented fusion seem to be preferable.     

Is there a stable vertebral height restoration with the new radiofrequency kyphoplasty? A clinical and radiological study

Purpose

The aim of this study is to evaluate whether radiofrequency kyphoplasty can restore vertebral body height in osteoporotic vertebral fractures and whether restoration of vertebral height correlates with decreased pain.

Methods

In a prospective study from December 2010 to October 2011, 25 patients underwent RF kyphoplasty for 30 fresh osteoporotic vertebral fractures. The parameter demographics, pain relief, restoration of vertebral body height (mean vertebral body height, kyphosis angle, anterior/posterior edge height) and all complications were recorded.

Results

Mean age of patients was 73.8 ± 9.6 (range, 55–83); time from initial painful fracture to treatment was 3.0 weeks ± 1.2; average operative time was 23.5 min (range, 15–41). Average pain index score decreased significantly from 69 ± 8.5 preoperatively to 34.4 ± 5.9 postoperatively (p < 0.001), and to 30 ± 6.3 (p < 0.001) after 3 months. Mean vertebral body height, anterior edge height and kyphosis angle showed significant increases postoperatively and at 3-month follow-up (p < 0.05). In two vertebrae (6.6 %), minimal, asymptomatic cement leakage occurred in the upper disc. After 2 months, one new fracture (3.3 %) was identified in the directly adjacent segment that was also successfully treated with radiofrequency kyphoplasty. There was a preliminary correlation between mean vertebral body height elevation and cement volume (r = 0.533).

Conclusion

Radiofrequency kyphoplasty achieves rapid and lasting improvement in clinical symptoms. There was stable restoration of vertebral body height with a mean cement volume of 3.0 ml ± 0.6. There was no correlation between restoration of vertebral body height and pain relief.     

Posterior vertebral column resection in early onset spinal deformities

Purpose

Early onset spinal deformities (EOSD) can be life-threatening in very young children. In the growing spine, surgical intervention is often unavoidable and should be carried out as soon as possible. A deformed section of the spine not only affects the development of the remaining healthy spine, but also that of the chest wall (which influences pulmonary function), the extremities and body balance. Posterior vertebral column resection (PVCR) represents an effective surgical solution to address such problems. However, reports in the literature concerning PVCR are mostly limited to its use in adolescents or adults. The purpose of this study was to illustrate our experience with PVCR in EOSD and to describe the surgical technique with respect to the unique anatomy of young children.

Materials and methods

Four children [mean age 3.7 (range 2.5–5.2) years] with severe spinal deformity underwent PVCR through a single approach. Multimodal intraoperative monitoring was used in all cases. Surgery included one stage posterior circumferential resection of one vertebral body along with the adjoining intervertebral discs and removal of all posterior elements. A transpedicular screw-rod system was used for correction and stabilisation. Fusion was strictly limited to the resection site, allowing for later conversion into a growing rod construct at the remaining spine, if necessary. Relevant data were extracted retrospectively from patient charts and long spine radiographs.

Results

The mean operation time was 500 (range 463–541) min, with an estimated blood loss of 762 (range 600–1,050) ml. Mean follow-up time was 6.3 (range 3.5–12.4) years. After PVCR, the mean Cobb angle for scoliosis was reduced from 69° (range 50–99°) to 29° (5–44°) and the sagittal curvature (kyphosis) from 126° (87–151°) to 61° (47–75°). The mean correction of scoliosis was 57 % (18–92°) and of kyphosis, 51 % (44–62°). There were no spinal cord-related complications. In three patients, spinal instrumentation for growth guidance (fusion less growing rod technique) was applied. Two patients had complications: one patient had a complication of anesthesia, halo pin failure, and revision surgery with extension of the instrumentation cranially due to loss of correction; the second patient had a postoperative infection, which required plastic reconstructive measures.

Conclusion

PVCR appears to be an effective technique to treat severe EOSD. There are important differences in its use in young children when compared with older patients. In patients with EOSD, additional surgical procedures are often necessary during growth, and hence non-fusion instrumentation beyond the vertebral resection site is advantageous, as it permits spinal growth and the later addition of fusion.     

Role of thoracoscopy for the sagittal correction of hypokyphotic adolescent idiopathic scoliosis patients

Purpose

Thoracic adolescent idiopathic scoliosis (AIS) curves (Lenke 1–4) are often characterized by hypokyphosis. Sagittal alignment remains challenging to correct, even with recent posterior segmental instrumentation. Some authors recommend anterior endoscopic release (AER) to reduce anterior column height, and facilitate thoracic kyphosis correction. The aim of this study was to assess the contribution of AER to sagittal correction in hypokyphotic AIS.

Methods

Fifty-six hypokyphotic (T4T12<20°) AIS patients were included. In group 1 (28 patients), patients first underwent AER, followed by posterior instrumentation and correction 5–7 days later. In group 2 (28 patients), patients underwent the same posterior procedure without AER. Posterior correction was performed in all cases using posteromedial translation and hybrid constructs consisting of lumbar pedicle screws and thoracic sublaminar bands. From radiological measurements performed using low-dose EOS radiographs, the correction of thoracic kyphosis was compared between the two groups.

Results

Groups 1 and 2 were comparable regarding demographic data and preoperative thoracic kyphosis (group 1: 11.7° ± 6.9° vs group 2: 12.1° ± 6.3°, p = 0.89). Postoperative thoracic kyphosis increase averaged 18.3° ± 13.6° in group 1 and 15.2° ± 9.0° in group 2. The benefit of anterior release was not statistically significant (p = 0.35).

Conclusion

Although previous studies have suggested that thoracoscopic release improved correction compared to posterior surgery alone, the current study did not confirm this finding. Moreover, results of the current series showed that no significant benefit can be expected from AER in terms of sagittal plane improvement when the posteromedial translation technique is used, even in challenging hypokyphotic patients.     

Retrospective analysis of treatment of thoracolumbar burst fracture using mono-segment pedicle instrumentation compared with short-segment pedicle instrumentation

Objective

To investigate the safety and therapeutic effects of mono-segmental pedicle instrumentation (MSPI) in treating thoracolumbar burst fracture (AO classification: A3.1 and A3.2).

Methods

A retrospective analysis was conducted on 60 cases with thoracolumbar burst fracture (AO classification: A3.1 and A3.2) between April 2005 and February 2010. Half of the 60 inpatients were treated with MSPI, and the other half was treated with short-segment pedicle instrumentation (SSPI). The mean operation time, blood loss, visual analog scale (VAS) and vertebral kyphotic angle before and after surgery were compared.

Results

In the MSPI group, the mean operation time was 90 ± 25 min, and the blood loss at operation was 180 ± 62 ml. The vertebral kyphotic angles were 17.3° ± 9.3° before surgery, 6.5° ± 6.5° one week after surgery, and 9.5° ± 6.4° for the latest follow-up. The VAS scores were 7.5 ± 1.4 before surgery, 2.5 ± 0.7 one week after surgery, and 1.4 ± 0.8 for the latest follow-up. In the SSPI group, the mean operation time was 101 ± 28 min, and the blood loss at operation was 203 ± 88 ml. The follow-up duration was 12–64 months. The vertebral kyphotic angles were 16.5° ± 9.1° before surgery, 7.1° ± 6.9° one week after surgery, and 7.5° ± 5.2° for the latest follow-up. The VAS scores were 6.7 ± 1.5 before surgery, 3.0 ± 0.4 one week after surgery, and 1.1 ± 0.6 for the latest follow-up. There were no statistically significant differences between these two groups in the operation time, blood loss at operation, VAS score and vertebral kyphotic angle before and after surgery (p > 0.05). The post-surgical VAS scores and vertebral kyphotic angles were significantly decreased in both groups, compared to before surgery (p < 0.05).

Conclusions

It is safe and effective to treat thoracolumbar burst fractures (AO 3.1 and AO 3.2) with MSPI. The mean operation time, blood loss at operation, post-surgical VAS and vertebral kyphotic angle of the MSPI group are similar, compared to the SSPI group. Further research is needed to find out whether therapeutic effects of MSPI are better than those of conservative treatment in these cases.     

Severe rigid Scheuermann kyphosis in adult patients; correction with posterior-only approach

Purpose

Scheuermann kyphosis is the most common structural kyphosis among adolescence and young people. Surgical treatment may be performed through combined anterior and posterior or posterior-only approaches; to our knowledge, the efficacy of posterior-only approach as less invasive procedure is not well studied in case of severe rigid Scheuermann kyphosis.

Materials and methods

Eighteen patients with severe rigid Scheuermann kyphosis operated through only posterior approach from 2013 to 2016 were evaluated. All information regarding demographic data, curve size before and after the surgery, surgical time, amount of blood loss, correction loss during follow-up and also complications was collected.

Result

There were six females and 12 males. Mean age of the patients was 22.4 years (range 17–38). Mean kyphosis angle before surgery was 87.2° (range 85–105), and that reduced to 47.4° (range 45–55) after the surgery. Mean curve size in hyperextension view was 73.8°. Mean postoperative Cobb angle was 50–55 percent of preoperative curves. Mean hospital admission duration was 3.5 days after the index surgery (range 3–5 days). Mean blood loss during the surgery was 250 ml. Mean surgical duration time was 150 min. Mean follow-up period was 9 months (range 8–48 months). No complication was found among the patients.

Conclusion

Posterior-only approach using advanced osteotomy techniques and posterior release is a safe and reliable approach for treatment of patients suffering from severe rigid Scheuermann kyphosis and provides acceptable deformity correction.

     

Sagittal alignment of the cervical spine in adolescent idiopathic scoliosis treated by posteromedial translation

Purpose

To analyze postoperative changes in the cervical sagittal alignment (CSA) of patients with AIS treated by posteromedial translation.

Methods

49 patients with thoracic AIS underwent posterior arthrodesis with hybrid constructs, combining lumbar pedicle screws and thoracic universal clamps. Posteromedial translation was the main correction technique used. 3D radiological parameters were measured from low-dose biplanar radiographs. CSA was assessed using the C2C6 angle, and the central hip vertical axis (CHVA) was used as a reference axis to evaluate patients’ balance.

Results

Preoperatively, 58 % of patients had thoracic hypokyphosis, and 79 % had a kyphotic CSA. Significant correlation was found (r = 0.45, P = 0.01) between thoracic hypokyphosis and cervical kyphosis. Increase in T4–T12 thoracic kyphosis (average 14.5° ± 10°) was associated with significant decrease in cervical kyphosis in the early postoperative period. The CSA further improved spontaneously during follow-up by 7.6° (P < 0.0001). Significant positive correlation (r = 0.32, P = 0.03) was found between thoracic and cervical improvements. At latest follow-up, 94 % of the patients were normokyphotic and 67 % had a CSA in the physiological range. Sagittal balance of the thoracolumbar spine was not significantly modified postoperatively. However, the procedure significantly changed the position of C2 in regard to the CHVA (C2–CHVA), which reflects headposition (P = 0.012). At last follow-up, the patients sagittal imbalance was not significantly different from the preoperative imbalance (P = 0.34).

Conclusions

Thoracic hypokyphosis and cervical hypolordosis, observed in AIS, can be improved postoperatively, when the posteromedial translation technique is used for correction. The cervical spine remains adaptable in most patients, but the proportion of patients with physiological cervical lordosis at final follow-up remained low (24.5 %).     

The posterior surgical treatment for focal kyphosis in upper-middle thoracic spine

Purpose

To analyze the clinical characteristics of focal kyphosis in upper thoracic spine, and observe the outcome of the posterior corrective surgical procedures.

Methods

Thirteen patients of focal kyphosis were treated with posterior surgical procedures in our medical center. The kyphosis apex was above T6 in all cases. The surgical procedures performed in this study included pedicle subtraction osteotomy (PSO) in six cases and vertebral column resection (VCR) in seven cases. For each case, the kyphosis angle, curvature of lower thoracic spine, lumbar lordosis angle, cervical lordosis angle, pelvic parameters, and the sagittal plane balance of the spine were compared before and after surgery. Neurological function change was assessed based on Frankel grading system and oswestry disability index (ODI).

Results

The average follow-up time of this study was 28.3 months. The average kyphosis angle was reduced from 73.5º before surgery to 32.7º immediately after surgery, and remained at 33.5º at follow-up. The average ODI improved from 22.5 before surgery to 15.5 at follow-up. The neurological function improved after surgery in eight cases. There were two cases of transient neurological deficiency in the lower extremities after VCR procedure, who eventually recovered under postoperative care. One case had recurrent kyphosis due to implant failure after VCR procedure, and recovered after the revision surgery.

Conclusions

Although high risk needs to be warned, the corrective surgery for focal kyphosis in upper thoracic spine still can achieve satisfactory results. Given the comparative surgical results yet less complications, PSO seems to be a preferable procedure over VCR for kyphosis at this region.